Masking in 2024: A Response
Yesterday, we published a piece by Catherine Sarkisian about her experience with, and reaction to, masking during a recent stint on an inpatient service. It would be an understatement to say that the piece stimulated a lot of discussion — in its first 12 hours, there were 186 comments on Sensible Medicine and my tweet about the article had been viewed 16,000 times. (I didn’t read every comment on this site – I do have an actual job -- but I was happy that most comments, ones that agreed or disagreed, were polite and thoughtful). David Rind sent me this article, a thoughtful, well-argued, reply. I think the reason I am still interested in this topic is that great points can be made “on either side” of the issue. This sort of exchange has been our goal on Sensible Medicine since the beginning.
“Always wearing a mask on a medical service in 2024 is an extreme measure and lies outside what should be considered acceptable professional behavior.”
Catherine Sarkisian, Article on Sensible Medicine
I’ve noticed that many clinicians seem to speak in absolutes more frequently when it comes to masking than with other issues. As such, I’ll start with a single absolute statement: with the strain of Covid that circulated in the spring of 2020, having the provider wear a surgical mask and eye protection and the patient wear a surgical mask was highly effective in an outpatient setting. I started seeing patients in a dedicated Covid clinic in April 2020 and we had no access to N95 masks. My very first morning in the clinic, I saw eight patients. Seven of them tested positive for Covid and I suspect the eighth test was a false negative. Over seven months in that clinic, surrounded by coughing, Covid-infected patients, no staff member developed Covid. Not one.
Enough with absolutes. I suspect that masking patients and providers remains at least somewhat effective in reducing transmission of SARS-COV2. If you think there are adequate data to prove that statement false, please cite the high-quality evidence. I also suspect it reduces transmission of various other respiratory viruses.
Covid was my second pandemic; I was in training as the AIDS pandemic hit. I watched clinicians refuse to walk in patient rooms, touch patients without gloves, or perform indicated procedures. This behavior was medically harmful and unnecessary, as well as being discriminatory. I also watched as universal precautions led to rapid changes in how providers dealt with blood. In the early 1980s, it was a mark of being a tough physician that contact with blood did not bother you. Wearing gloves for IV placement meant that you couldn’t feel veins as well. Within a short period of time, it was considered inappropriate to be in ungloved contact with blood and behaviors evolved.
Patients may think that a masked provider is appropriately fearful, needlessly worried, protecting them, hiding from them, or any number of other things. In fact, the decision to wear a mask is completely impersonal. A doctor who wears a mask with every patient is not singling out a patient or a disease.
Physicians who trained during Covid got as used to the shield of wearing a mask as I did to wearing gloves when touching blood. That shield may make them feel safe and comfortable and they may be better doctors for it. It may let them hide their faces and emotions and be less awkward for it. It may interfere with communicating compassion and empathy and make patient interactions more fraught for it.
I watched as teenagers returned to school after masking was no longer required. Some students quickly discarded masking, some did so within days, some weeks, and some months. As the culture shifted, eventually nearly every student went to school without a mask. I don’t see some terrible consequence of letting the same culture shift occur gradually among medical trainees.
My hospital has instituted and removed masking for outpatient care several times now as respiratory infections have waned and waxed. Just this week, masking restrictions were again lifted. Personally, I will go back to my prior practice. I will wear a mask with patients who wear masks. I model this with the residents I precept. I will also wear an N95 and eye protection with patients who have respiratory symptoms. I’ve had Covid and I don’t enjoy it, but my goal is to keep patients comfortable and to avoid spreading viruses to my patients. There is a comfort to wearing a mask when I occasionally sniffle or sneeze and wonder if I might be harboring some virus – I can think I’m doing my best to protect my patients – but I also really like having my face uncovered for my patients, and that preference wins.
But I don’t see the need to speak in absolutes or inflict my masking preferences on trainees. There is so much else for them to learn.
David Rind is an academic primary care physician at Beth Israel Deaconess Medical Center and the Chief Medical Officer for the Institute for Clinical and Economic Review. Prior to his work at ICER, he was Vice President of Editorial and Evidence-Based Medicine at UpToDate.
Photo by Li Lin
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Masks have been widely tested and used in practice for hundred of years. Ignoring that research and experience, as if masks were invented in 2020 is strange. So far, about twenty levels of protection of the respiratory system have been developed, against dust, organic and inorganic gases, liquids, oil aerosols, high temperature gases and so on. Viruses are nothing special, they are small solid matter, particles, dust. The approach in practice is simple - if protection level x does not filter good enough, try x+1.
Cloth and surgical masks are not designed to filter aerosols and they are not adequate. If they were used, it is because "better something than nothing" reasoning.
The lowest level of mask designed to filter particles is the rarely used FFP1, and it filters out 80%. The second level is FFP2/N95. Filters at least 94/95% of 0.3 micron particles and MORE virus size (~99%). They were often used in medical practice, although they were often not used consistently. Then there are two levels of disposable respirators above that - FFP3/N99 and N100. They filter 99% and 99.97% of particles. Then there are levels of protection above that - elastomeric half masks, elastomeric full masks, PAPR, with various HEPA filters, hazmat suits level B and level A.
Anyone who believes that protection level x doesn't work, but instead of saying "OK, let's start using protection level x+1" says "let's drop masks", has a serious problem with logic, or more likely he is intellectually dishonest.
A little late to the party, but people are really hanging their hats on Cochrane and their mask review. Curious what you think about this - "All-cause mortality and fatal and non-fatal CVD events were reduced with the use of statins as was the need for revascularisation (the restoration of an adequate blood supply to the heart) by means of surgery (coronary artery bypass graft ) or by angioplasty (PTCA). Of 1000 people treated with a statin for five years, 18 would avoid a major CVD event which compares well with other treatments used for preventing cardiovascular disease. Taking statins did not increase the risk of serious adverse effects such as cancer. Statins are likely to be cost-effective in primary prevention." I'm guessing most of you don't agree with Cochrane on this, but they are the gospel on masking???